Applicant/Business Name:______________________________________ Website: (Complete Supplement A for all Named Insured’s if necessary)
Street/City/County:___________________________________________________ State: ____ Zip: __________ Member of HBA? Yes, No # _____________ CGB, CGR, CGP, GMB, GMR attach certificate(s) for discount Amount of Work Performed: Homebuilding Remodeling Commercial
1. a. Est’d # Starts This Year/Last Year: ______/______ _____/______ _______/________ b. 2nd Prior Year: _____________ ___________ ________________ c. 3rd Prior Year: _____________ ___________ ________________ d. AVG Construction Cost: _____________ ___________ ________________ e. Total Construction Cost (1a X 1d) _____________ ___________ ________________ Starts = Total projected Single Family homes &/or Multi Family units (not buildings)
Construction Cost = Total Sales price less land costs or Total Cost of Construction plus Profit.
2. Average number of months to complete a Home: ________
3. Total Construction Cost Range: _________/________ ________/_________ ________/________ 4. Sales Price Range: _________/________ ________/_________ ________/________ 5. Last year’s Total Construction Cost ____________ ___________ ________________
6. Commercial Work - Describe type of work done: ____________________________________________________ 7. Gross Sales or Revenue projected this year: _______________________, Last Year: ________________________ 8. Provide # years in business under this name: _________. # of years in business under all prior names: __________
a. Do you work in any other states(s)? Yes, No. If yes, list state(s): ________________________________ b. Have you worked in any other states in the past? Yes, No. If yes, list states: ______________________ 9. Most of your work is: _________% Subdivisions/Developments, _________% Scattered site construction = 100%
__________% Single-Family (S-F) __________% Multi-Family (M-F)* = 100%
(M-F) = duplexes, tri-plexs, 4 plexs, etc., apartments, condominiums, OR attached single family row/townhomes Do you build Condominiums? Yes, No; Apartments? Yes, No
10. Complete Supplement B – Project List for all development/subdivision construction work done over the last 3 years and currently in progress and planned for the future.
11. How many job site Supervisors do you have? ____________
12. Do you conduct regular worksite safety inspections? Yes, No Frequency? _______________________ 13. Have you ever worked on hillsides, cliffs, landfills or other areas subject to subsidence? Yes, No. If yes,
what precautions are taken? _____________________________________________________________________ 14. Do you buy old homes, renovate and sell them? Yes, No
15. Do you perform fire or flood damage restoration work? Yes, No .
Homebuilders Coverage Program
TM16. Builders Risk Coverage, Limits, Deductible. Indicate the coverage options you would like included in quote: Limits: Maximum any one Bldg/Dwelling: __________________ Maximum any one Loss: _________________
$10,000 Temporary Location & Transit Limit provided for each. If higher limits desired indicate below. Temporary Location Limit: _______________ Transit Limit: _______________
Deductible Requested: $1,000 $2,500 $5,000 $10,000 Other:$___________________ Soft Costs (Delay in Construction): Limit Requested $25,000, $50,000. $75,000 $10,000 Outdoor Property, Trees, Plants, Sod & Shrubs included. Higher limit, if desired: _____________
Contract Change Endt (higher limit options due to change order): 5%, 10%, 15%, 20% Earthquake Coverage Earthquake Zone Required: ____________ Limit: ___________________________ Flood Coverage Flood Zone Required: ________________ Limit: ___________________________ Deductible Desired: $1,000 $2,500 $5,000 Other: ___________________ Fire Protection: Indicate which of the following apply to the areas where you build.
Protection Classes (PC) if known: 1-5, 6-8, 9-10. Fire Department: Paid Volunteer Distance to: Fire Dept: 5 miles or less, Over 5 miles,
Distance to: Fire Hydrant: 1000’ or Less, Over 1000’
Water: At what point in the construction phase is water brought in to activate new Fire Hydrants?
____________________________________________________________________________________________
If Fire Hydrant is over 1,000’ or Fire Dept is over 5 Miles Away: Describe in detail the available private fire protection to ensure an adequate supply of water & the ability to get it to the
fire:________________________________________________________________________________________ ____________________________________________________________________________________________
Do you build near Coastal Waters? Yes, No. If yes, # miles from coast? ___________________________ Homes: What is the maximum # completed homes (you still own) or under construction at one time that are
separated by less than 150’ __________. What’s the typical # of homes meeting these conditions? __________ Site Security: Describe in detail (e.g., fencing, lighting, security/patrol/guard service, etc.):
______________________________________________________________________________________________ __________________________________________________________________________________________
Model Homes: # Models:____ AVG Construction Cost:_____________Profit must be included in Construction Cost Model Contents: Average Contents Value:___________________ AVG Months as Model: __________
Model Homes and Inventory Homes Complete below or attached separate spread sheet
Model Homes Addresses /Date
Completed
Home / Contents Values Include Profit in Value
/ / / / / / / / / / / /
Homes in Inventory Addresses /Date
Completed
Completed Value Include Profit in Value
/ / / / / / /
WARRANTY, AUTHORIZED SIGNATURE AND CONTINUING DUTY TO UPDATE
The undersigned is an authorized representative of the Applicant and acknowledges that the information provided above and with the application, including supplements, attachments, and replies to the underwriter inquiries, and applications from other insurance companies which have been submitted to Homebuilders Coverage, Inc. or its subsidiaries and made a part of the application:
1. Will be relied upon by Homebuilders Coverage Inc. in determining the acceptability of the prospective Name Insured and the premium to be charged;
2. Are true, accurate, and complete; and
3. Will be an integral part of any resultant contract.
The undersigned further agrees that the prospective Named Insured has a continuing duty, through date of policy inception, to update the application, including all supplements, attachments and replies to underwriter inquiries. Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance, or a claim containing any false or deceptive information, or conceals information concerning any fact material thereto, commits a fraudulent act, which may be a crime.
Applicant’s Signature: Date:
Multiple-Named Insureds Supplement A (Copy as Needed)
Complete the following for each additional name/entity to be considered as a Named Insured
Named Insured: ______________________________________________________ First Named Insured’s ownership%? _______ 1. Describe their operations: _______________________________________________ Yrs in Bus:______ Active/Inactive? _____ 2. States worked/working in: _______________ If active, are their exposures included in Acord GL Application? Yes, No 3. If Contractor,
a. Do you or have you worked for other contractors? Yes, No. b. Perform fire or flood restoration work? Yes, No
c. Do Commercial Construction? Yes, No
4. If Homebuilder:
a. Have or do you build over 50 homes or Multi Family units in any of your development(s)? Yes, No b. If you build Multi Family homes, do you build 5-plex or larger Multi Family buildings or apartments? Yes, No
Named Insured: ______________________________________________________ First Named Insured’s ownership%? _______ 1. Describe their operations: _______________________________________________ Yrs in Bus:______ Active/Inactive? _____ 2. States worked/working in: _______________ If active, are their exposures included in Acord GL Application? Yes, No 3. If Contractor,
a. Do you or have you worked for other contractors? Yes, No. b. Perform fire or flood restoration work? Yes, No
c. Do Commercial Construction? Yes, No
4. If Homebuilder:
a. Have or do you build over 50 homes or Multi Family units in any of your development(s)? Yes, No b. If you build Multi Family homes, do you build 5-plex or larger Multi Family buildings or apartments? Yes, No
Named Insured: ______________________________________________________ First Named Insured’s ownership%? _______ 1. Describe their operations: _______________________________________________ Yrs in Bus:______ Active/Inactive? _____ 2. States worked/working in: _______________ If active, are their exposures included in Acord GL Application? Yes, No 3. If Contractor,
a. Do you or have you worked for other contractors? Yes, No b. Perform fire or flood restoration work? Yes, No
c. Do Commercial Construction? Yes, No
4. If Homebuilder:
a. Have or do you build over 50 homes or Multi Family units in any of your development(s)? Yes, No b. If you build Multi Family homes, do you build 5-plex or larger Multi Family buildings or apartments? Yes, No
Named Insured: ______________________________________________________ First Named Insured’s ownership%? _______ 1. Describe their operations: _______________________________________________ Yrs in Bus:______ Active/Inactive? _____
Supplement B - Project List – Future, Current & Past (Copy as Needed for each Entity)
Entity Name: __________________________________________________ Policy Effective Date: ______________
Complete the following for future, current & past projects over the last 10 years S-F = Detached Single Family; M-F = Multi-Family
Apt = Rental Apartments (Shown separately below)
HOA = Home Owners Association; COA = Condominium or Condo Owners Association
Development/ Subdivision Start & End Multi-Family Up to 4 Plex Multi-Family 5 Plex or More Total # Apt Total # S-F
(List All Phases) Date Buildings Units Buildings Units Units Homes
1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
